HomeMy Public PortalAbout9542 WEDGEWOOD ST_Swimming Pool__ �.' V1:-)RKERS'CAMFENSATION DECLARATION
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I hereby affirm%hat I ho.e a certificate of consent to self �p� w�
�rt�,ure;or d'c�•rtlta.ate of Workers'Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL P�� ��
cv a certifie-I o�v thereof rSec 3800, Lab. C.) 76Ar0B
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Policy N (� Company ,[ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
BUILDING `�
Certified copy is filed with the c ty building inspec- FOR APPLI NT TO FILL IN ADDRESS
tion deparlm nt BUILDING
�� / --/y10A�(i ADDRESS / LOCALITY
Dote Applicant/ f �— '
CERTIFICATE OF EXEMPTION FROM WORKERS' CIN '—<y L� ZIP ® CRO55%REST
COMPENSATION INSURANCE SIZE OF ASSESSOR
(This section need not be completed if the permit is for one TRACT LOT I LOT NO MAP BOOK PAGE PARCELTEL .
? /l MA
I certify that in the performance of the work for which this ) I NO
SPECIAL
permits issued, I shall not employ any person in any manner ADDRESS CONDITIONS
so as to become subject to the Workers'Compensation Laws. DISTRICT STATISTICAL CLASS TYPE PRO
ep CLASS NO. SED BY
CITY ZIP r,�({/ CO 5T.
ID r rn
Date Applicant ARCHITECT OR ll O {�
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER W-6, N a —�
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS �- 44
with comply with such provisions or this permit shall be TEL. $ QD VALIDATION
deemed revoked. CONTRACTOR N
LICENSED CONTRACTORS DECLARATION ADDRESS LIC.
I hei eby affirm that I am licensed under provisions of Chapter 9 $
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and si ec CITY CLASS G` �-3
`/� DESCRIPTION OF WORK FINAL
License Number Lic. Class v SWIMMING POOL r,.y'- / /y�' �[ �/J DATE
a� /� SPA / f'.6i�GT/;L ��iJ J
Contractor Date V- / FINAL O
SQ. FT. By / V
I am exempt under Sec. SIZE 0
B BP.0 for this reason ELECTRICAL U
Date: ft� W
Steel &Conduit Bonding 5 1 1.3 A 0.
Signature Conduits, Conductors, EquipmentDhzt C/)SINGLE FAMILY # 0 0 0 0 2 1 Z
HOME OWNER-BUILDER DECLARATION PLUMBING 1 0 o84,79$4,']9
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Poo
P-Trap o 0 0 [j 7 9
Professions Code): Gas System LE
I, as owner of the property, will do the plumbing and Anti-Syphon 07.23-86
L
lectrical work. I,or my employees with wages as their
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater
CONSTRUCTION LENDING AGENCY `5 , U (r1
I hereby affirm that there s a construction lending agency for APPLICANT TEL.
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.y IPRINT I NO. 1 - 295.50
Lender's Nor ADDRESS too o o
_ 2955(;5,
Lender's Ad ess 0
PC Fee S Permit Fee �J 1 V J 7,e'L—C 6
1 certify that h read this a li ation and state that the _
above inform n is correct. I a e to comply with all County Issuance Fee Q
ordinance and tate laws r g to building, electrical,
m than of and p mbin ruction,and hereby authorize Investigation Fee el
r ou ty to enter upon the above- I Total Fee .561
m nt ed prep r i s ch n urposes2 ,.J
2-119 Z
Signal a of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE